Embed Size (px)
Citation preview
A Collaborative Approach to Integrating Mental Health Services
with Pediatrics and Obstetrics for an Urban Population
Mercy St. Vincent Medical Center Healthy Connections
Healthy Connections: Multi-disciplinary Team Presenters:
Celeste Smith, MA, PC Connie Cameron, RN, MSN, CNS
Team: Licensed Independent Social Workers,
Professional Clinical Counselors, Clinical Nurse Specialist, Early Childhood Specialist, Physicians, Residents, Nurses
Learning Objectives:
1) Identification of key differences between the co-location and the behavioral health consultation model of service delivery within the medical home
2) Ways to effectively adapt a medical home to incorporate behavioral health consultation model
3) Learn skills necessary to help traditionally trained mental health professionals shift into integrated services
Outline
Need for integration of services Co-location model in pediatrics Outcomes in pediatrics Behavioral health consultation model in
obstetrics Outcomes in OB Funding services
Incidence of Mental Illness Nationally
14-20% children with mental health problems
75% do not receive services Not receiving services: 69% white, 78%
African American, 86% Hispanic/Latinos
National Health Interview Study
Incidence in Lucas County, OH Lucas County, youth population of 148,818 29,763 (20%) needing mental health
services 3,300 served through community mental
health system
Need for integration of services
Reduced Stigma Improved Access to Care Reduced Chronicity and Improved Social
Integration Human Rights Protection Better Health Outcomes for people treated
in Primary Health Care
Need for Women
Problem Doctors/nurses identifying children
with emotional and behavioral problems
Referred to community mental health system
Families not accessing services Limited or no communication between
providers
Healthy Connections: Origin
Began integrated mental health services at St. Vincent Family Care Center in 1997 to increase access and utilization of mental health services and improve collaboration and communication between providers
Healthy Connections’ Goal of Integrated Services
To improve access to and utilization of mental health services for community-based populations of children, adolescents and their families through integration of primary health care and behavioral health care services.
Objectives
Increase number of clients receiving behavioral health services
Improve communication between providers Decrease negative emotional and behavioral
symptoms Increase the level of functioning in
participants
Models of Integration
Co-location model: Mental health services are provided in the
same building Services involve a comprehensive
biopsychosocial assessment and psychotherapy oriented interventions
Models of Integration
Co-location model: Diagnosis and treatment plans are created
separate from the medical team Records are kept in separate files and
information shared intermittently
Models of Integration
Collaborative Model: Mental health services are provided in the
same building Services involve a comprehensive
biopsychosocial assessment and psychotherapy oriented interventions
Progress towards goals are shared at regular intervals with the doctors/nurses
Models of Integration
Collaborative Model: Diagnosis and treatment plans are created
in collaboration with the medical team but clinical responsibility stays with the mental health provider
Records are kept in separate files but shared
Models of Integration
Behavioral Health Consultation (BHC) Model: Mental health clinician is part of the
health care team and provides services in the clinic
Symptom focused assessment and interventions to improve functioning
Brief, solution focused intervention
Models of Integration Behavioral Health Consultation (BHC)
Model: Diagnosis and treatment plan are a shared
responsibility with the physician Records are part of the medical chart
Healthy Connections at Four Sites
St. Vincent Mercy Family Care Center Pediatrics (FCC)
University of Toledo Medical Center Pediatrics (UTMC)
Toledo-Lucas County Health Department Pediatrics & Obstetrics (HD)
UTMC Ryan White HIV/AIDS Clinic
Total Visits by Site and Type of Service
1333
4
517
12758 32
93
11 40
200
400
600
800
1000
1200
1400
FCC FCC BHC UTMC UTMC
BHC
Ryan
White
Ryan
White BHC
HD HD BHC MaPCP
FCC FCC BHC UTMC UTMC BHC Ryan White Ryan White BHC HD HD BHC MaPCP
Key Factors for Integration
Documentation and information sharing Funding and sustainability Diagnosing mental health disorders Shifting the mindset of clinical staff Developing resources Overcoming referral obstacles Becoming part of the medical team
St. Vincent Family Care Center Pediatric Services
60% of the children live with single mothers Over 80% of the families live in poverty 97% use Medicaid for health care Primarily Collaborative services with
immediate access if needed (e.g., crises)
St. Vincent Family Care Center Pediatric Services
FCC Demographics
22%7%3%
68% Black, notHispanicWhite, notHispanicHispanic
Other
St. Vincent Family Care Center Pediatric Services
Key Factor: Documentation and Information Sharing Communication both verbal and written Collaboration on diagnosis, treatment plan,
and follow-up Physician Communication Form SOAP note format PSC screening/ assessment tools, testing Beware of language barriers
St. Vincent Family Care Center Pediatric Services Key Factor: Funding and sustainability
SVMMC Foundation Mercy Children’s Hospital Foundation OH Hospital Association AAP CATCH grant HRSA Healthy Tomorrows HRSA Integrated Mental Health ACF Women’s Health: Perinatal Depression
St. Vincent Family Care Center Pediatric Services
Key Factor: Funding and sustainability Certification as a community mental
health center – site specific Accredited through Cenpatico for
Medicaid HMO billing Reimbursement low
University of Toledo Medical Center Pediatric Services Diverse population from large geographic
area 60% use Medicaid for healthcare Many patients are dealing with congenital
and chronic medical conditions Resident training clinic History of Collaborative services and recent
shift to include BHC services
University of Toledo Medical Center Pediatric Services
UTMC Demographics
50%40%
10% White, notHispanic
Black, notHispanic
Hispanic
University of Toledo Medical Center Pediatric Services
Key factor: Diagnosing mental health disorders Developing ways to gather information as
a team Utilizing assessment tools effectively Only gathering information necessary for
diagnosis
University of Toledo Medical Center Pediatric Services Key factor: Shifting the mindset of clinical
staff Focus on presenting problem and
functional restoration Staying with the referral question Completing consultations in < 30 minutes Functional Analysis Assessments and
specific interventions
University of Toledo Medical Center Pediatric Services
Key Factor: Developing Resources One page handouts (e.g., psychoeducation) Providing information for the clinic staff on
mental health issues
Staff is the KEY to successful integration
KNOW YOUR STUFF!!!! And be available!
Toledo-Lucas County Health Department Pediatric & OB/GYN Services
Located in downtown area and serves the highest risk, transient and homeless families
Equal amount of Collaborative and BHC services offered
Toledo-Lucas County Health Department Pediatric & OB/GYN Services
LCHD Insurance Breakdown
23%5%
10%
62% Uninsured
Medicaid
PendingMedicaidOther
Toledo-Lucas County Health Department Pediatric & OB/GYN Services
LCHD Demographics
8%5%
42% 45%
Black, notHispanic
White, notHispanic
Hispanic
Other
Toledo-Lucas County Health Department Pediatric & OB/GYN Services
Key factor: Overcoming referral obstacles
Using referral resources well Referred out for psychiatric services that
are needed or when more services are needed that therapist/BHC cannot provide.
Toledo-Lucas County Health Department Pediatric & OB/GYN Services
Key factor: Overcoming referral obstacles
Increasing referrals for BHC •Being available on site/present in clinic •Checking schedules for past patients •Presenting problems •Site can identify specific “red flags”
University of Toledo Medical Center Ryan White HIV/AIDS Clinic
In 2007, 510 infected and affected HIV consumers
Age ranged from newborn to 62. Expected increase of 30 (15%) new HIV
infected consumers predicted this year Ryan White Part C component, Early
Intervention serves another 417 HIV infected clients
University of Toledo Medical Center Ryan White HIV/AIDS Clinic
192
51
24 10 170
50
100
150
200
UTMC/Ryan White Demograpics
Women
Men
HIV Exposed
Infants
Infected Children
Youths
University of Toledo Medical Center Ryan White HIV/AIDS Clinic
UTMC/Ryan White Demographics
36%8%
56%
Hispanic
Black, notHispanic
White, notHispanic
University of Toledo Medical Center Ryan White HIV/AIDS Clinic
Primarily BHC services at this site
Referrals for psychotherapy if warranted or wanted • Knocking on the door with interruptions …
patients prefer a more personal therapeutic setting
• Patients who don’t comply with services outside of clinic
University of Toledo Medical Center Ryan White HIV/AIDS Clinic
Key factor: Becoming part of the medical team Ryan White’s medical team consists of
physicians, nurses, medical case managers, social worker, behavioral health consultant, nutritionist, psychiatric clinical nurse specialist, patient advocate, OB/GYN
University of Toledo Medical Center Ryan White HIV/AIDS Clinic
Key factor: Becoming part of the medical team Medical/Nursing care – how nurses and MDs
identify mental health issues and call therapist in for a consultation or for crisis situations
Trust established by front line worker then transferred to therapist
Support groups – HIV and mental health info for patients
University of Toledo Medical Center Ryan White HIV/AIDS Clinic
Key factor: Becoming part of the medical team Educational information about mental health
issues for staff Formal case consultations with all members of
the team versus specific staffing with needed clinical staff (AIDS Resource Center)
Being part of the agency meetings (increase presence in clinic)
Healthy Connections: Objectives & Outcomes
1. Improve access to mental health services for underserved, disenfranchised, and
low income children and families
433 children and teenagers served during the past 12 months through
2,179 visits
Total Visits by Site
1337
644
90 104
40
200
400
600
800
1000
1200
1400
1600
FCC UTMC Ryan White HD MaPCP
FCC UTMC Ryan White HD MaPCP
Number Served by Site and Type of Service
193
3
94
55
38
19 219
10
50
100
150
200
250
FCC FCC BHC UTMC UTMC
BHC
Ryan
White
Ryan
White
BHC
HD HD BHC MaPCP
FCC FCC BHC UTMC UTMC BHC Ryan White Ryan White BHC HD HD BHC MaPCP
Total Visits by Site and Type of Service
1333
4
517
12758 32
9311 40
200
400
600
800
1000
1200
1400
FCC FCC BHC UTMC UTMC
BHC
Ryan
White
Ryan
White BHC
HD HD BHC MaPCP
FCC FCC BHC UTMC UTMC BHC Ryan White
Ryan White BHC HD HD BHC MaPCP
Healthy Connections: Objectives & Outcomes
2. Provide early recognition and intervention for emotional and
behavioral issues affecting children who are currently unable to access services
68% have been seen within 2 weeks of
referral, 83% have initial therapy appointment within 2 weeks of
intake.
Healthy Connections: Objectives & Outcomes
3. Improve utilization of services through increased appointment show rates
The overall show rate was 80%
Show Rate by Site
79%82%
97%
69%
57%
0%
20%
40%
60%
80%
100%
120%
FCC UTMC Ryan White HD MaPCP
FCC UTMC Ryan White HD MaPCP
Show Rate by Site and Type of Service
79%
100%
82%
89%95%
100%
68%
79%
57%
0%
20%
40%
60%
80%
100%
120%
FCC FCC BHC UTMC UTMC
BHC
Ryan
White
Ryan
White BHC
HD HD BHC MaPCP
FCC FCC BHC UTMC UTMC BHC Ryan White Ryan White BHC HD HD BHC MaPCP
Healthy Connections: Objectives & Outcomes
4. Improve behavioral and emotional outcomes for children
Problem severity and functioning measured with Ohio Outcome
Scales.
OH Outcome Scales
Problem SeverityProblem Severity
%youth in non%youth in non--clinical rangeclinical range(score<20)
0
10
20
30
40
50
60
70
80
90
100
Youth Parent Worker
Initial
90 day
OH Outcome Scales
FunctioningFunctioning
%youth in non%youth in non--clinical rangeclinical range(score>50)
0
10
20
30
40
50
60
70
80
90
Youth Parent Worker
Initial
90 day
Healthy Connections: Objectives & Outcomes
5. Improve patient’s satisfaction with services.
Satisfaction questionnaire
showed 96% of clients were satisfied with integrated mental health
services.
Skills needed to assist trained mental health professionals
RETHINK ROLES Face to face time with clients between 5 and
30 minutes (prioritize issues) Team approach that includes the patient Mental health professionals must foster
trusting relationships with primary care staff Learn to communicate a very complicated
patient to a primary care physician in about 30 seconds
Funding Services
Grants Federal State Local Private and Public Insurance
Summary
Integration of mental health services works and can fill a HUGE need in your community
The level of integration depends on the needs of the clinic and the population being served
Communication, Communication, Communication
Assertive problem solving and a “CAN DO” attitude
St. Vincent Mercy Medical Center, Healthy Connections Aaron Cromly 419.251.2310 [email protected]
Tanya Toyer 419.251.2415 [email protected]
Connie Cameron 419.251.2453 [email protected]
Resources Robinson, P.J. & Reiter, J.T. (2007). Behavioral
Consultation and Primary Care: A Guide to Integrating Services. New York, NY: Springer
ICARE Partnership: Mind and Body – Together http://www.icarenc.org/
Mountainview Consulting Group http://www.behavioral-health-
integration.com/news.php Harlem United Community AIDS Center
http://www.harlemunited.org/index.htm
References For additional Toledo, Ohio and Lucas County demographic information,
see http://www.city-data.com/city/ Toledo-Ohio.html and http://www.city-data.com/county/Lucas_County-OH.html.
Large numbers of Ohioans lack dental, vision, mental health, and/or prescription medication coverage. For additional information, see http://www.healthpolicyohio.org/pdf/OHInsuranceCoverage2006.pdf and http://www.healthpolicyohio.org./pdf/MapHealthExSummary.pdf.
For additional information on the Lucas County Family Council: The Status of Children and Families in Lucas County report, see http://64.233.169.104/search?q=cache:0ojv-onTUWkJ:www.co.lucas.oh.us/familycouncil/Status_of_Children_%26_Families.pdf+Lucas+County+Youth+Needs+Assessment&hl=en&ct=clnk&cd=4&gl=us.
References U.S. Department of Health and Human Services. (2001). Report of a
Surgeon General’s working meeting on the integration of mental health services and primary health care. Rockville, MD. http://www.surgeongeneral.gov/library/mentalhealthservices/mentalhealthservices.PDF,
Harrison, Myla E., McKay, Mary M., Bannon, William M. (April 2004). “Inner-City Child Mental Health Service Use: The Real Question is Why Youth and Families Do Not Use Services,” Community Mental Health Journal, Vol. 40, No. 2.
National Health Interview Study, see http://www.cdc.gov/nchs/nhis
